Maintenance for Wakefulness Testing (MWT)

Similar documents
Maintenance for Wakefulness Testing (MWT)

Your Sleep Study will begin the night of at 8 p.m. and will end the following day between 6 a.m. and 7 a.m.

Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed

Baptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:

Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine

130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History

Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox

I would like for my patient to be seen in Sleep Medicine consultation and managed by the sleep physician. Yes No

Sleep Questionnaire. 2. How long has this problem bothered you? My Main Sleep Complaints: - Trouble sleeping at night For how many months/ years?

PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:

Associated Neurological Specialties and Sleep Disorder Center

SLEEP HISTORY QUESTIONNAIRE

Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address

Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:

Huron Medical Sleep Center Saad S. Ahmad, MD

Sleep Disorders Center of Santa Maria

Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )

SLEEP DISORDERS CENTER QUESTIONNAIRE

Denver, CO Welcome Packet

604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA SLEEP HISTORY QUESTIONNAIRE

Humble Dreams Sleep Center. Humble, TX 77339

SLEEP QUESTIONNAIRE. Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone:

Sleep Symptoms & History

Sleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:

New Patient Sleep Intake

*521634* Sleep History Questionnaire. Name of primary care doctor:

Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120

Huron Medical Sleep Center Saad S. Ahmad, MD

Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118

Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. For how many months/years?

Robert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study

PATIENT DEMOGRAPHICS

Sleep History Questionnaire

Huron Medical Sleep Center Saad S. Ahmad, MD

SLEEP STUDY - PATIENT QUESTIONNAIRE

PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:

Sleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)

Section of Pediatric Sleep Medicine

Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)

Patient History & Sleep Questionnaire

Your physician has ordered a sleep study for you on. Your arrival time is scheduled for.

PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)

Sleep Center New Patient Questionnaire

General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status

Intake Questionnaire

MEDICAL HISTORY QUESTIONNAIRE

WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS

Sleep Medicine Associates

SLEEP QUESTIONNAIRE. Please briefly describe your sleep or sleep problem:

SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:

Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy

Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305

LIBERTY SLEEP ASSOCIATES, LLC SLEEP DISORDERS CENTER

Home Sleep Testing Questionnaire

BMI: Family physician : Neck circumference (cm) Hypertension + 4 cm Snoring + 3 cm Witnessed apnea + 3cm Total

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:

Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D.

993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:

THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE

493 Blackwell Road, Suite 317-A, Warrenton, VA

Nash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax:

Please complete this questionnaire before your appointment.

Brunswick Pulmonary and Sleep Medicine Lawrence Davanzo, DO, FCCP 49 Veronica Ave, Somerset, NJ Phone# Fax#

PATIENT SLEEP QUESTIONNAIRE

THE PERMANENTE MEDICAL GROUP

ST CHARLES HOSPTIAL SLEEP DISORDERS CENTER SLEEP QUESTIONNAIRE. Patient Name: Date of Birth: SS# Address: Male Female

EPWORTH SLEEPINESS SCALE

Date of Study: Arrive at: P.M.

SLEEP & MEDICAL HISTORY QUESTIONNAIRE

Sleep Questionnaire. Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago:

1960 FP CENTER FOR SLEEP DISORDERS

Adolescent Sleep Disorder Questionnaire For Children Ages PATIENT NAME: (Please print clearly) Patient s Date of Birth: Age: Male Female

Kelowna Sleep Clinic Dr. Ronald Cridland Inc Sleep Questionnaire

The Medical Center Sleep Center

PATIENTS DEMOGRAPHICS

SLEEP SCREENING QUESTIONNAIRE

Height: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other

Pre-Test Questionnaire. Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over

SLEEP STUDY CANCELLATION/ NO SHOW POLICY

Tallahassee Memorial Sleep Center Patient Questionnaire

Polysomnography Patient Questionnaire

Sleep History Questionnaire

The following questions are about your sleep. Please consider both what others have told you about your sleep and what you know yourself.

Dear Patient: You have an appointment scheduled with SIMEDHealth Pulmonology.

Dr. Michael Baten is The Santa Fe SleepDoctor NEUROLOGY / ADULT AND PEDIATRIC SLEEP MEDICINE

Sleep Medicine Questionnaire

PEDIATRIC SLEEP EVALUATION

Rex Surgical Specialist (Bariatric Office)

PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely

SLEEP SCREENING QUESTIONNAIRE

MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:

Instructions. If you make a mistake, put an "X" over the checkmark. Then put a checkmark in the correct box and draw a circle around that box.

SLEEP STUDY. Nighttime. 1. How many hours of sleep are you now getting in a typical night?

Sleep Study Appointment Date: Time: 8:00 PM

YOUR NAME AGE DATE. Comments. Describe your sleep problem and how long you ve had it

Sleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your

EMORY SLEEP CENTER Sleep and Health Questionnaire

Sleep Study Information

1. a. Please state in your own words why you (or your physician) asked for a sleep evaluation.

Transcription:

Maintenance for Wakefulness Testing (MWT) Dear, Your Maintenance for Wakefulness Testing (MWT) will begin on the morning of at 7 a.m. and will end at 5 p.m. ARRIVAL TIME: If you are not able to arrive at 7 a.m. or unable to report as scheduled please notify the Sleep Disorders Staff within 48 hours by calling 517-545-6690. If you do not notify us, you may be billed $250.00. For scheduling changes, please call Central Scheduling at 734-712-1313 Option 2 PLEASE READ THE FOLLOWING CAREFULLY 1. LOCATING THE SLEEP CENTER: The is located on the campus of St. Joseph Mercy Livingston Hospital in Howell. Parking is available in front of the building. Enter the main building and take the elevators next to the pharmacy, up to the third floor, turn left down the hallway and the is at the end of the hall. 2. PRIOR TO TESTING: Please register for your Maintenance for Wakefulness test by calling 800-676-0437, Monday through Friday between the hours of 8 a.m. and 5 p.m. Be sure to get good nights sleep prior to testing. 3. DAY OF TESTING: Do not drink caffeine or take any stimulants to encourage wakefulness. Urinalysis sampling is required. 4. WHAT TO EXPECT: The Technologist will apply sensors to your head and torso. Four 40 minutes sessions will take place sitting in a recliner with the lights out and you will be asked to stay awake. Please dress comfortably. 5. MEALS: Lunch will be provided. If you have any questions, please notify the Sleep Disorder Center staff by calling 517-545-6690. Thank you for allowing St. Joseph Mercy Livingston to provide you with this service. 12602-005 N 7/16 (M) MWT Questionnaire (Page 1 of 5)

Sleep Questionnaire (Page 1) Fill out completely and bring with you the night of the test. Name: Date of Birth: _ Sex: Male Female Height Weight Neck size _ Check all that apply: I snore or have been told I snore I have been told I stop breathing during sleep I wake up choking, gasping, or short of breath I wake myself up with my snoring I am sleepy during the day I am fatigued throughout the day I fall asleep unintentionally during the day I have memory loss I have problems with concentration I am a restless sleeper I kick my legs at night I have restless legs syndrome I have insomnia How long have you had symptoms that you know of: How does this affect your life and daily activities? What time do you typically go to bed and get up: Weekdays BEDTIME a.m./p.m. WAKE Time a.m./p.m. Weekends BEDTIME a.m./p.m. WAKE Time a.m./p.m. On average, how long do you actually sleep at night? hrs mins Medical History Anemia Diabetes Other blood-borne disease Arthritis Heart Disease Prostate problems Asthma Hepatitis B or C Reflux Cancer Hypertension Seizures COPD Kidney problems Stroke/TIA s Depression/anxiety Migraine headaches Thyroid problems Other (please describe): Allergies (include latex or tape) List Your Current Medications 12602-005 N 7/16 (M) MWT Questionnaire (Page 2 of 5)

Sleep Questionnaire (Page 2) Restlessness I am a restless sleeper I kick or jerk my legs and/or arms during sleep I have restlessness, tingling or crawling sensation in my legs or arms I am unable to keep my legs still prior to falling to sleep I grind my teeth in my sleep Other Complaints When falling asleep or waking up, I sometimes feel paralyzed (unable to move) At night my heart pounds, beats rapidly or beats irregularly I have a lot of nightmares I sleepwalk I have seen or heard things that weren t real when waking up or going to sleep I get sudden weakness or feel like I will fall when I laugh or get angry Other Questions Do you have a regular bed partner?... Yes On average, how long does it take you to fall asleep at night after you turn out your bedroom lights/ minutes? What do you usually do just before turning out the lights and trying to go to sleep (read, watch TV, bath, etc) On average, how often do you wake up during the night? Do you wake up too early, unable to go back to sleep?... Yes Do you usually awaken to an alarm or spontaneously on your own?... Yes Do you nap or go back to bed after getting up?... Yes If so, how many times per day? Average length of nap? Do you feel more refreshed after the nap?... Yes Are you bothered by sleepiness during the day?... Yes Do you feel that you get too much sleep at night?... Yes Do you feel that you get too little sleep at night?... Yes Do you usually feel tired during the day?... Yes If so, why do you think this is so? Social History Do you smoke? How much? When did you quit? Do you drink alcohol? How often? Do you drink caffeine? How often? Do you use marijuana or other non-prescription drugs? If so, what? I am a shift worker on rotating shifts I am a permanent or long term night shift worker 12602-005 N 7/16 (M) MWT Questionnaire (Page 3 of 5)

Sleep Questionnaire (Page 3) Family History Is there any one in your family with a sleep problem? If so, please describe: Epworth Sleepiness Scale Use this scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Sitting and reading... Watching TV... Sitting in a public place for example, a theatre or meeting... As a passenger in a car for an hour without a break... Lying down to rest in the afternoon... Sitting and talking to someone... Sitting quietly after lunch (when you have had no alcohol)... In a car, while stopped in traffic... Please check all that apply: I take daytime naps I have had auto accidents as a result of falling asleep while driving I fight to stay awake while driving I have had injuries as a result of falling asleep in the daytime Daytime sleepiness is affecting my job or quality of life Total: Best way to reach you: Home Phone: Work Phone: Cell Phone: Other Phone: Email Address: I authorize the St. Joseph Mercy Sleep Disorders Lab and/or Pulmonary and Critical Care Associates sleep coordinator to leave results via my phone or email address provided. Signature Date: Time: 12602-005 N 7/16 (M) MWT Questionnaire (Page 4 of 5)

Driving Directions St. Joseph Mercy Livingston, 517-545-6690 on the campus of St. Joseph Mercy Livingston From the North Take US 23 South to Exit 67 (Highland Road/M-59). Merge onto MI-59 W/Highland Rd via Exit 67 toward Howell. Drive approximately 11 miles and make a U-turn onto W/Highland Rd /MI-59. Turn Right onto Byron Road. Drive for about ½ mile, Livingston Hospital will be on your right. From the South Take US-23 North to I-96 Exit 60B, left toward Brighton/Lansing. Merge onto I-96 W via the ramp on the left toward Lansing. Take Exit 137 toward County Hwy-D19/Howell/Pinckney. Turn Left onto Pinckney Rd. (Becomes Michigan Ave/MI-155) Drive approximately 1 mile and turn Left onto W Grand River Ave. Turn Right onto Byron Rd. Drive for about ½ mile, Livingston Hospital will be on your left. From the East Take I-96 West to Exit 137 (Hwy D-19/Howell/Pinckney) Turn Left onto Pinckney Rd. (Becomes Michigan Ave/MI-155) Drive approximately 1 mile and turn Left onto W Grand River Ave. Turn Right onto Byron Road. Drive for about ½ mile, Livingston Hospital will be on your left. HOWELL N BRIGHTON DiscoverRemarkable Interstate/freeways to St. Joseph Mercy Livingston St. Joseph Mercy Livingston DiscoverRemarkable From the West Take I-96 East to Exit 133, (MI-59 Exit). Merge onto MI-59/W Highland Rd. Drive approximately 2 ½ miles and turn Right onto Byron Road. Drive for about ½ mile, Livingston Hospital will be on your right. For Directions from your Home address, please visit: http://www./locations 292194 SJMAA CampusMap(3.16).indd 2 St. Joseph Mercy Livingston campus follow signs to the smap(3.16).indd 2 12602-005 N 7/16 (M) MWT Questionnaire (Page 5 of 5)

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback